Cardiovascular risk factor knowledge, risk perception & actual risk in HIV-infected adults

1. Cardiovascular risk factor knowledge, risk perception & actual risk in HIV-infected adults Patricia A. Cioe, Ph.D, RN Brown University September 15, 2012

2. Purpose To describe cardiovascular risk factor knowledge and CVD risk perception in a cohort of HIV-infected adults

3. Background and Significance • Advances in the medical treatment of persons infected with HIV over the past 25 years have led to an increased lifespan for HIV-infected individuals (Bhaskaran et al., 2008; Lewden et al., 2007) • CVD is leading cause of death in U.S.(American Heart Association, 2009) and has emerged as a major cause of morbidity & mortality in HIV-infected persons • CVD accounted for 23.8% of all non-HIV-related deaths in HIV-infected persons (Sackoff et al., 2006) • Acute MI rates per 1000 person-years were significantly higher (11.13 vs. 6.98, p<.05) in HIV-infected adults compared to matched controls (Triant et al., 2007)

4. Background & Significance • The increased incidence of MI and increased prevalence of CVD in this population is multi-factorial • The literature suggests that persons with HIV infection have: • A higher prevalence and degree of premature coronary atherosclerosis (Grunfeld et al., 2009; Guaraldi et al., 2009; Hsue et al., 2004; Kingslet et al., 2008; Lo et al., 2010; Van Vonderen et al., 2009) • A higher prevalence of cigarette smoking, and diabetes (Fri-Moller et al., 2003; Glass et al., 2006; Kaplan et. Al., 2007) • Chronic inflammation (Hadigan et. Al., 2003; Kuller et. Al., 2008) • Research in non-HIV-infected populations suggests that knowledge of CVD risk factors significantly influences perception of risk (Choi, Rankin, Stewart, Oka, 2008; Christian, Mochari, & Mosca, 2005)

5. Specific Aims • 1. to describe: the estimated risk of CVD; the perceived risk of CVD; and, the level of risk factor knowledge in HIV-infected adults • 2. to describe the relationship between estimated and perceived risk of CVD in HIV-infected adults • 3. to examine the influence of CVD risk factor knowledge on perceived risk of CVD in a sample of HIV-infected adults

6. Individual Perceptions Modifying Factors Likelihood of Action Perceived Benefits minus Perceived Barriers (Health Insurance status) Sociodemographic Variables (Age, gender, race, ethnicity, education level, employment status) Structural Variables (Knowledge/Heart Disease Fact Questionnaire; Estimated Risk) Perceived Susceptibility to CVD (Perception of Risk of Heart Disease Scale) Perceived Severity of CVD Likelihood of Taking CVD Preventive Behaviors Perceived Threat of CVD Cues to Action (Family History of CVD, Personal history of DM, HTN, Elevated Cholesterol) Theoretical Framework: Health Belief Model (Adapted from Stretcher, V. & Rosenstock, IM., 1997)

7. Design & Procedures • Descriptive study, cross-sectional design • One study visit - face-to-face interviews • Laboratory data were obtained from the medical record • IRB approval was obtained at UMMS and at RI Hospital • Study procedure and instruments were piloted with 9 participants

8. Sample and Setting • Convenience sample – 130 adult participants • Recruited from 2 hospital-based HIV clinics in RI • Recruitment took place as patients presented to clinic for their scheduled appointments • 40 individuals were screened but not recruited for participation

9. Inclusion & Exclusion Criteria • Inclusion Criteria: 1. males & females over age 18 2. HIV-infected per the medical record 3. able to read and speak English 4. ability to give written informed consent • Exclusion Criteria: 1. unable to read and understand English 2. Had an established dx of CVD (AMI or CVA) in medical record 3. Had a past CVD event (MI or stroke) or intervention (CABG, stent placement, vascular surgery)

10. Measures/Instruments • Perceived Susceptibility: • Perception of Risk of Heart Disease Scale; alpha = .78 in this sample(Ammouri & Neuberger, 2008) • Structural Variables: • Knowledge: Heart Disease Fact Questionnaire; alpha = .74 in this sample (Wagner, Lacey, Chyun, & Abbott, 2006) • Estimated Risk: Framingham Risk Score • Sociodemographic Variables: • Age, gender, race, ethnicity, education level, employment status • HIV Clinical Variables: • Duration of HIV infection, antiretroviral medications, CD4, viral load, Nadir CD4 • Cues to Action: • FH of CVD, Personal History of DM, HTN, Elevated cholesterol • Perceived Barriers: • Health insurance status

11. Data Management • All participants were assigned a unique research ID • Written informed consent was obtained prior to enrollment • De-identified data was kept on a password protected research-designated drive which was backed up nightly • Double entry was performed to ensure accuracy

12. Data Analysis • Descriptive stats (frequencies, means, SDs, percentages) were calculated for all demographic data • Pearson correlation statistic was used to describe the relationship between estimated and perceived risk of CVD (aim #2) • Linear regression was used to examine the influence of RF knowledge on perceived risk of CVD (aim #3) • Statistical significance was accepted at the 95% confidence interval level (p<.05) • All statistics were performed using SPSS Version 17.0

13. Pilot Data • Purpose of pilot • Nine participants • Findings: • Study interview – 30-40 minutes • Consent form was adequate • Data collection sheet was well organized • Heart Disease Fact Questionnaire – no issues • Perception of Risk of Heart Disease Scale – 2 issues • Pilot of alternate risk scale with 4 of the participants • Index of Perceived Risk Scale (Becker & Levine, 1987)

14. Results

15. Results • Clinical Variables: • 87% currently on ART • Mean CD4 546 • Undetectable viral load in 71.5% • HCV AB+ 49% • 12% on methadone or suboxone • CVD Risk Factor Variables: • 48.5% had a mean BP consistent with a diagnosis of pre-hypertension (120 -139 systolic or 80 - 89 diastolic) • Only 7% of participants were involved in smoking cessation efforts • 76.2% of participants reported never discussing CVD risk with their HCP

16. Results • T chol 170 (SD 36) • LDL 97 (SD33) • HDL 44 (SD 17) • FPG 96 (SD 25) • BMI 27 (SD 5.5) • Daily ASA 7% • Diabetes 10% • On statin med 8.5%

17. Results • Framingham risk score • Mean FRS = 7.87 (SD 6.0, range 1-25) • 1/3 of participants had FRS in moderate or high risk categories (>10% risk) • Perceived risk of heart disease • Mean = 53.1 (SD 5.8, range 27-68) • Heart Disease Fact Questionnaire • Mean = 19.0 (SD 3.5, range 6-25)

18. Results Estimated and perceived risk were significantly correlated, though weakly (r (126) = .24, p = .01) Controlling for age, risk factor knowledge was not predictive of perceived risk (F (1, 117) = .13, p > .05)

19. Limitations and Strengths • Convenience sample • Cross-sectional analysis • Self-report/interview format • Generalizability • Instruments used • First study to measure CVD risk factor knowledge and perceived risk in HIV infected adults • Low level of missing data (<5%)

20. Conclusions/Implications HIV-infected patients in the U.S. are living longer due to the efficacy of antiretroviral therapy CVD has emerged as an important cause of death in this population Traditional risk factors (smoking, prehypertension, and being overweight) are highly prevalent Despite a fair level of RF knowledge, knowledge did not inform perception of risk Research and efforts to improve CV risk perception and risk factor knowledge are needed Innovative interventions to reduce risk in this population need to be developed

21. Acknowledgments This project was supported by a National Research Service Award F31 Ruth Kirschstein grant no. 1F31NR012656 from the National Institute for Nursing Research Contact information: Patricia_Cioe@brown.edu

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